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SAN JOAQUIN COUNTY _ ?NVIRONMENTAL HEALTH DEPARTMENT�/ 7100 East Main Street,Stockton,CA 95202-3029— Telephone:(209)468-3420 Fax.(209)468-3433 Web.www.sjgov.orglehd ABOVEGROUND PETROLEUM STORAGE PROGRAM SURVEY FORM Facility Name: `T /V {� U © Page of Faciat Address: City: Inspection Da 7 77k) aja X G4h, 0 1111191P FA N: PR#: Program Element: Uba $ 7-830 Tank/Container Information Complete for all sites with cumulative aboveground storage of petroleum 21320 gallons in tanks and containers over 55 gallons. Complete one box for each tank or each cumulative container product Tank(2820) ❑ Containers (2821) #of Containers: TA#: �erj J�J rj 7 (>250 gallons) (>55 gallons and<250 gallons) 1 Product Type: f Total Capacit} /000 gallons (per lank or cumulative for containers by product type) Install Date: Tank (2820) ❑ Containers (2821) #of Containers: TAM 6517J� 73 (>250 gallons) (>55 gallons and<250 gallons) 2 Product Type: _ 45 _ Total Capacity: ,sem gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TAM (>250 gallons) (>55 gallons and<250 gallons) 3 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: _ ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 4 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: ❑ Tank(2820) ❑ Containers (2821) #of Containers: TA#: (>250 gallons) (>55 gallons and<250 gallons) 5 Product Type: Total Capacity: gallons (per tank or cumulative for containers by product type) Install Date: Total Capacity this Page: O fJ gallons Total Capacity for Site: j f SOD gallons Comments: EHD Inspector Reviewed / Date: / Entered Date: CBy Initial: '. `(_�••Ui0/ By Initial: // END 28-01 - 01/16/08